Japanese Dermatological Association Guidelines: Outlines of Guidelines for Cutaneous Squamous Cell Carcinoma 2020

In consideration of the development of treatment options for squamous cell carcinoma (SCC), the Japanese Skin Cancer Society issued the first guidelines of SCC in 2007 and revised them in 2015. Here, we report the English version of the 2020 edition of the Japanese SCC guidelines. The first half of this article is an overview of SCC including actinic keratosis and Bowen's disease, and the second half discusses three clinical questions: (i) treatment of actinic keratosis; (ii) determination of the resection margin of the primary lesion; and (iii) treatment of radically incurable cases, as contemporary problems encountered in treating SCC. In these evaluations, all processes were implemented according to the Grading of Recommendations, Assessment, Development, Evaluation system. Also, items of recommendation concerning each clinical question were determined by a multidisciplinary expert panel consisting of dermatologists, plastic/reconstructive surgeons, radiologists, and oncologists through a comprehensive literature search and systematic reviews.

Exploration of a standard treatment for Buruli ulcer through a comprehensive analysis of all cases diagnosed in Japan

Buruli ulcer (BU) is a refractory skin ulcer caused by Mycobacterium ulcerans or M. ulcerans ssp. shinshuense, a subspecies thought to have originated in Japan or elsewhere in Asia. Although BU occurs most frequently in tropical and subtropical areas such as Africa and Australia, the occurrence in Japan has gradually increased in recent years. The World Health Organization recommends multidrug therapy consisting of a combination of oral rifampicin (RFP) and i.m. streptomycin (SM) for the treatment of BU. However, surgical interventions are often required when chemotherapy alone is ineffective. As a first step in developing a standardized regimen for BU treatment in Japan, we analyzed detailed records of treatments and prognoses in 40 of the 44 BU cases that have been diagnosed in Japan. We found that a combination of RFP (450 mg/day), levofloxacin (LVFX; 500 mg/day) and clarithromycin (CAM; at a dose of 800 mg/day instead of 400 mg/day) was superior to other chemotherapies performed in Japan. This simple treatment with oral medication increases the probability of patient adherence, and may often eliminate the need for surgery.

Distal Phalangeal Metastasis of Extramammary Paget's Disease

A rare case of phalangeal metastasis of extramammary Paget's disease in a 68-year-old man is described. The patient developed an erythematous, slightly elevated area in the pubic region. A biopsy specimen demonstrated numerous, large, rounded cells with ample pale-staining cytoplasm proliferating in the epidermis. With a diagnosis of extramammary Paget's disease, he underwent wide local excision and inguinal node dissection. Eleven months postoperatively, the patient developed a tender, red, swollen right ring finger. Bone X-ray showed that the distal phalanx of the ring finger had completely dissolved. Histopathological examination demonstrated proliferation of tumor cells in the adipose tissue. They had poorer and darker cytoplasm than the Paget's cells in the epidermis of the pubic region. Immunohistochemically, these cells showed the same staining pattern as did the Paget's cells at the primary site. Accordingly, the patient was diagnosed with distal phalangeal metastasis of extramammary Paget's disease. Two weeks after the appearance of the distal phalangeal metastasis, the patient died of cancerous pleurisy. It has been reported that patients with phalangeal metastasis have a very poor prognosis.

Drug Eruption Due to Peplomycin: An Unusual Form of Stevens-Johnson Syndrome with Pustules

A rare case of Stevens-Johnson syndrome (SJS) due to peplomycin in a 48-year-old man is described. The patient had squamous cell carcinoma on the scalp and underwent preoperative neoadjuvant chemotherapy with peplomycin. On the fifth day of the chemotherapy, he developed a fever and multiple dusky violaceous erythematous areas and pustules on his trunk, thighs, and palms. Erosive erythema and erosions also developed on his soles, scrotum, and oral mucosa. A biopsy specimen taken from the eruption on the thigh revealed marked liquefaction degeneration of the basal layer of the epidermis. Laboratory examinations demonstrated aggravation of liver function. Additionally, the patient developed conjunctivitis and corneal erosions. Although he had some subcorneal pustules, we diagnosed the case as an unusual form of SJS because of severe mucous membrane involvement. Oral prednisolone was administered, and the symptoms subsided. Then the patient underwent wide local excision. One month after surgery, we performed patch tests and a lymphocyte stimulation test with negative results. Then we re-administered peplomycin starting with 1/20 of a daily dose and gradually increasing the dose each day. After administration of the regular daily dose, the patient had a relapse of fever, eruptions, stomatitis, corneal erosions, and liver dysfunction. Therefore, a definite diagnosis of drug eruption due to peplomycin was made.

Collagen?poly glycolic acid hybrid matrix with basic fibroblast growth factor accelerated angiogenesis and granulation tissue formation in diabetic mice

Because poor skin wound healing associated with diabetes is thought to be partly a result from impaired angiogenesis, treatments that improve angiogenesis could have important clinical applications. We herein report the effects of novel developed material, collagen-poly glycolic acid fiber hybrid matrix, being used together with basic fibroblast growth factor to promote wound healing of full-thickness skin defects on the back of type 2 diabetic Lepr(db) mice. Our data indicates that this therapeutic approach markedly promotes angiogenesis and granulation tissue formation in comparison with other conditions 14 days after wounding.

Chemoradiation using low-dose cisplatin and 5-fluorouracil in locally advanced squamous cell carcinoma of the skin: a report of two cases

Recently, low-dose 5-fluorouracil/cisplatin induction concurrent with radiation (chemoradiation) has been reported to be effective for locally advanced squamous cell carcinoma of the otorhinolaryngologic and gynecologic regions. However, to date, this therapeutic option has not been evaluated for squamous cell carcinoma of the skin. We evaluated chemoradiation therapy using cisplatin and 5-fluorouracil in two patients with locally advanced squamous cell carcinoma of the skin. Administration of cisplatin and 5-fluorouracil was conducted concurrently with conventionally fractionated radiation therapy. Cisplatin (patient 1: 4 mg/m(2)/d on days 1 to 5; patient 2: 15 mg/m(2)/d on days 1 to 5) and 5-fluorouracil (patient 1: 400 mg/m(2)/d for 7 days; patient 2: 850 mg/m(2)/d for 5 days) were administered intravenously for 1 hour and for 24 hours, respectively. Patient 1 underwent two courses of chemotherapy with a 3-week interval, and patient 2 underwent a single course of chemotherapy. The primary tumor of both patients showed complete regression, leaving ulceration. In patient 1, the ulceration completely resolved after 3 months. Patient 2 underwent surgical resection and full-thickness skin grafting. A histopathologic examination confirmed complete tumor regression. Neither patient suffered any serious side effects during this treatment. We conclude that chemoradiation using cisplatin and 5-fluorouracil was effective in these two patients with locally advanced squamous cell carcinoma of the skin. Several randomized studies have shown concurrent chemoradiation to be superior to radiation alone. This regimen is an option in managing patients who have unresectable primary tumors or who require preservation of local function.

Silencing of Peroxiredoxin 2 and aberrant methylation of 33 CpG islands in putative promoter regions in human malignant melanomas

Aberrant methylation of promoter CpG islands (CGI) is involved in silencing of tumor suppressor genes and is also a potential cancer biomarker. Here, to identify CGIs aberrantly methylated in human melanomas, we did a genome-wide search using methylation-sensitive representational difference analysis. CGIs in putative promoter regions of 34 genes (ABHD9, BARHL1, CLIC5, CNNM1, COL2A1, CPT1C, DDIT4L, DERL3, DHRS3, DPYS, EFEMP2, FAM62C, FAM78A, FLJ33790, GBX2, GPR10, GPRASP1, HOXA9, HOXD11, HOXD12, HOXD13, p14ARF, PAX6, PRDX2, PTPRG, RASD1, RAX, REC8L1, SLC27A3, TGFB2, TLX2, TMEM22, TMEM30B, and UNC5C) were found to be methylated in at least 1 of 13 melanoma cell lines but not in two cultured normal melanocytes. Among these genes, Peroxiredoxin 2 (PRDX2) was expressed in normal melanocytes, and its expression was lost in melanomas with methylation. The loss of expression was restored by treatment of melanomas with a demethylating agent 5-aza-2'-deoxycytidine. In surgical melanoma specimens, methylation of PRDX2 was detected in 3 of 36 (8%). Furthermore, immunohistochemical analysis of PRDX2 showed that disappearance of immunoreactivity tends to associate with its methylation. PRDX2 was recently reported to be a negative regulator of platelet-derived growth factor signaling, and its silencing was suggested to be involved in melanomas. On the other hand, 12 CGIs were methylated in >or=9 of the 13 melanoma cell lines and are considered as candidate melanoma biomarkers.

Promoter methylation profiling of 30 genes in human malignant melanoma

Aberrant methylation and demethylation of promoter CpG islands lead to silencing of tumor-suppressor genes and abnormal expression of normally methylated genes, respectively. Here, we analyzed human melanomas for their methylation and demethylation profiles. Methylation status of core regions in promoter CpG islands was examined for 20 (candidate) tumor-suppressor genes, 4 genes that are not considered as tumor-suppressors, but are frequently silenced in human cancers, and 6 normally methylated melanoma antigen genes (MAGEs). Analysis of 13 melanoma cell lines and 2 cultured normal human epidermal melanocytes (HEMs) showed that 9 tumor-suppressor genes and all 4 non-tumor-suppressor genes were methylated in at least 1 cell line, but never in HEMs, and that all 6 MAGE genes were demethylated in 3 to 13 cell lines. Interestingly, we detected no methylation of MGMT, PTEN, MTAP and p27, which were previously reported as silenced in melanomas. Furthermore, 3 genes that were frequently methylated in the cell lines and 6 MAGE genes were analyzed in 25 surgical melanoma samples. RARB, RASSF1A and 3-OST-2 were methylated in 5 (20%), 9 (36%) and 14 (56%) samples, respectively. MAGE-A1, A2, A3, B2, C1 and C2 were demethylated in 9 (36%), 22 (88%), 20 (80%), 7 (28%), 21 (84%) and 16 (64%) samples, respectively. At least 1 gene was methylated in 18 (72%) samples and at least 1 was demethylated in 24 (96%) samples. No correlation between frequent methylation and frequent demethylation was observed. These profiles showed that both aberrant methylation and demethylation occur widely in human melanomas.

Silencing of the thrombomodulin gene in human malignant melanoma

The loss of thrombomodulin (TM) expression is associated with tumour growth, infiltration and lymph node metastasis in human tumours. In melanoma cell lines, TM is reported to mediate cell adhesion, and its introduction into TM-negative melanoma cell lines suppresses their growth. In this study, we analysed TM expression in surgical melanoma specimens and the role of its promoter methylation in the loss of its expression. In 15 (75%) of the 20 specimens (five from a primary site and 15 from metastatic sites), melanoma cells lacked TM immunoreactivity. Methylation of the TM promoter region was detected in 10 (67%) of the 15 TM-negative specimens by methylation-specific polymerase chain reaction, whereas methylation was detected in two (40%) of the five TM-positive specimens. In cell lines, complete methylation of the TM promoter CpG island was detected in six (46%) of 13 melanoma cell lines, whereas no methylation was detected in two cultured normal melanocytes. There was a good correlation between the methylated status of the CpG island and the loss of TM messenger RNA (mRNA) expression. Treatment of melanoma cell lines with a demethylating agent, 5-aza-2'-deoxycytidine, induced demethylation of the promoter CpG island and the restoration of mRNA and protein expression. These findings suggest that most human melanomas lack TM expression, and that methylation of the promoter CpG island is one of the mechanisms responsible.

Mucinous nodules on the skin overlying a rheumatoid arthritic joint

A rare case of mucinous nodules on the skin overlying rheumatoid synovitis in a 79-year-old man is described. The patient had a five year history of RA. The patient had complained of arthralgia in the left elbow joint, and X-ray demonstrated narrowing of thejoint space along with bone destruction. He underwent an intraarticular injection of dexamethazone and lidocaine. Three weeks later, he noticed two dome-shaped nodules about 5 mm in size developing on the elbow. Histopathological examination demonstrated poorly defined mucinous nodules in the upper dermis. The mucinous material positively stained with alcian blue and colloid iron, and was metachromatic with toluidine blue. These positive stainings disappeared after hyaluronidase digestion. Five to six weeks after being resected, both nodules recurred. Lesional injections of triamcinolone were effective. The intraarticular injections preceding the appearance of the nodules might have created channels from the joint space to the skin. Leakage of activated synovial cells, which produced hyaluronic acid, through the channels might have caused the mucinous stroma of the nodules.

Association between polymorphisms in the SPINK5 gene and atopic dermatitis in the Japanese

Atopy, which is characterized by increased levels of immunoglobulin E (IgE) against common environmental allergens, is considered the strongest predisposing factor for asthma and atopic dermatitis (AD). Mutations in the gene encoding serine protease inhibitor Kazal-type 5 (SPINK5) are responsible for Netherton syndrome, a rare skin disorder characterized by greatly elevated IgE levels with atopic manifestations. A recent study of Caucasian AD families showed that maternally derived alleles of the SPINK5 gene are associated with development of AD and asthma, suggesting the parent-of-origin effect for the development of atopic diseases in the SPINK5 gene. We studied the possible association of the SPINK5 gene for the development of atopic diseases by determining the genotypes of five polymorphisms in a Japanese population. Ttransmission disequilibrium tests revealed an association of SPINK5 polymorphisms with AD but not with asthma. Our data indicate that the SPINK5 gene is associated with AD across ethnicities.

Mutation and association analysis of the interferon regulatory factor 2 gene (IRF2) with atopic dermatitis

Interferon regulatory factor 2 (IRF-2) is a member of a family of transcriptional factors involved in the modulation of cellular responses to interferons (IFNs) and viral infection as well as in the regulation of cell growth and transformation. Irf2 knockout mice show T helper 1 (Th1) cell development defect and spontaneous development of an inflammatory skin disease. To determine if there are any mutations in IRF2 associated with development of atopic dermatitis (AD), we screened for mutations in the 5' flanking and coding regions of IRF2 in AD patients and control subjects by single-strand conformational polymorphism (SSCP) analysis. We found three mutations in the promoter region ([-829C>T, -830C>T], -684C>T, and -467G>A), one silent mutation in exon 9 (921G>A), and a 10-bp deletion in the 3' untranslated region (1739[ATCCC]8>6). Among them, the -467G allele and the haplotype of the -467G, 921A, and 1739(ATCCC)8 alleles were transmitted preferentially to AD-affected children (P = 0.02 and P = 0.007, respectively). Our data suggest that IRF-2 plays some role in the development of AD in the Japanese population.

[Analysis of factors influencing on Anisakis specific IgE antibodies]

Anisakis-specific IgE (AsIgE) was examined in 84 cases of acute urticaria (AU) and 100 cases of atopic dermatitis (AD). Gender, age, disease category (AU or AD) and serum IgE value of the patients were compared with AsIgE. Univariate analysis showed that there was significant correlation between age and AsIgE, and between serum IgE and AsIgE. Serum IgE was significantly higher in AD than in AU. Age was significantly higher in AU than in AD. AsIgE was positive value in 26 cases (31%) of AU and 25 cases (25%) of AD. There were no significant differences between them. In these cases, however, AsIgE was significantly higher in AU than in AD. Percentage of patients with high AsIgE value (> class 2) was significantly higher in AU (20 cases, 24%) than in AD (3 cases, 3%). Multivariate analysis using discriminant analysis and logistic regression analysis showed that the most influential factor on AsIgE was disease category (relative risk = 16.87), and the second was age (relative risk = 1.05). Serum IgE and gender were considered not to influence on AsIgE. It is possible that Anisakis or related antigens have something to do with urticaria in AU patients with high AsIgE value.

Individual solvation numbers around the nickel(II) ion in an N,N-dimethylformamide and N,N-dimethylacetamide mixture determined by Raman spectrophotometry

Individual solvation numbers around the nickel(II) ion have been determined by titration Raman spectroscopy in N,N-dimethylformamide (DMF) and N,N-dimethylacetamide (DMA) mixtures at 298 K. The in-plane bending vibration (delta(O=C-N)) of DMF and the stretching vibration (v(N-CH3)) of DMA were used in the present analysis. These Raman bands of solvent molecules shift to higher frequencies upon coordination of the solvent molecules to the metal ion. By analyzing the band intensities of free and bound solvent molecules with increasing concentration of the metal ion, the solvation number around the metal ion can be evaluated. Because the individual solvation numbers of DMF and DMA around the nickel(II) ion in the mixture are determined independently, the total solvation number is obtained as their sum. It was found that the total solvation number remains 6 in all mixtures of the DMA mole fraction x = 0 - 1. Although DMF and DMA have practically the same electron-pair donor capacities, the nickel(II) ion prefers DMF to DMA, and an equal solvation number is attained at x = 0.75. This is ascribed to the solvation steric effect of DMA.

Formation of Copper(II) Thiocyanato and Cadmium(II) Iodo Complexes in Micelles of Nonionic Surfactants with Varying Poly(ethylene oxide) Chain Lengths

Formation of copper(II) thiocyanato and cadminum(II) iodo complexes in micelles of poly(ethylene oxide) (PEO)-type nonionic surfactants with varying PEO chain lengths of 9.5 (Triton X-100), 30 (Triton X-305), and 40 (Triton X-405) has been studied by titration spectrophotometry and calorimetry at 298 K. In a given surfactant solution, all data obtained were analyzed by assuming formation of ternary complexes MX(n)Y(m)((2-n)+) (M = Cu(II),Cd(II); X = SCN(-), I(-); Y = surfactant), and the complexes thus form in aqueous phase (m = 0) or in micelles (m = 1). In the Cu(II)-SCN(-) system, spectrophotometric data obtained by varying concentrations of the surfactant can be explained well in terms of formation of Cu(NCS)(2)Y in micelles and Cu(NCS)(+) and Cu(NCS)(2) in an aqueous phase, and it turned out that formation constant of Cu(NCS)(2)Y increases with increasing PEO chain length. In the Cd(II)-I(-) system, the formation of CdI(3)Y(-) and CdI(4)Y(2-) is concluded in micelles, and that of CdI(+), CdI(3)(-), and CdI(4)(2-) in an aqueous phase. Interestingly, formation enthalpies of CdI(3)Y(-) and CdI(4)Y(2-) become significantly less negative with increasing PEO chain length. This suggests that transfer of the complexes from aqueous solution to a hydrophobic octylphenyl (OP) moiety in micelles is significantly more exothermic than that to a hydrophilic PEO one. Thermodynamic parameters of transfer of CdI(3)(-) and CdI(4)(2-) from aqueous solution to the OP and PEO moieties of micelles have been evaluated. Copyright 2000 Academic Press.

Comparison of phototoxicity mechanism between pulsed and continuous wave irradiation in photodynamic therapy

A study has been conducted in which HeLa cells are incubated with hematoporphyrin derivative (HpD) for 1 h (1 microgram/ml of HpD in PBS) to compare the use of continuous wave (CW) and pulsed laser (10 Hz repetition rate and 7-9 ns pulse width) light for photodynamic therapy. Cytotoxic effects on the cells are evaluated by the 3-(4,5-dimethyl-2-thiazolyl)-2-5-diphenyl-2H-tetrazolium bromide (MTT) assay and the fluorescein diacetate (FDA)/propidium iodide (PI) stain method using a flow cytometer. The type of cell death is estimated by analysis of the DNA content and observation of the nuclear morphology. The cytotoxicity ratio of cells irradiated by pulsed laser light is estimated to be lower than that for CW laser light. The viability of cells that received pulsed laser light gradually decreases, whereas no significant changes are found in the cells irradiated with CW laser light with the elapse of post-irradiation time. The type of cell death differs between the pulsed and CW laser light irradiations. These findings suggest that the cytotoxic efficacy of the excitation light source is displayed by the difference in the type of cell death, namely apoptosis or necrosis.

Metastasis of esophageal carcinoma manifesting as whitlow-like lesions

A rare case of phalangeal metastasis of esophageal carcinoma in an 81-year-old man is described. The patient developed a tender, red, and swollen right index finger. From the clinical features, he was erroneously diagnosed with whitlow at first and treated with antibiotics with no success. A bone X-ray showed that the distal phalanx of the index finger was completely dissolved. Histopathological examination revealed proliferation of squamous cell carcinoma into the deep dermis. It is important to understand that the phalangeal metastases commonly display inflammatory symptoms that mimic acute infection.

Papillary eccrine adenoma: immunohistochemical studies of keratin expression

Despite various studies, there are serious disagreements about the cellular differentiation of papillary eccrine adenoma. In the present study, 2 specimens of papillary eccrine adenoma were analyzed by immunohistochemical techniques, using a panel of monoclonal antibodies against keratins, to elucidate its differentiation. Histopathologically, the tumor was composed of multiple tubular structures lined by two or more layers of epithelial cells. The luminal cells of the tubules were flattened or cuboidal. The former were noted in large dilated tubules. The latter were usually observed in small-to-moderate-sized tubules, and formed intraluminal papillary projections in some tubules. Immunohistochemically, there were two kinds of cuboidal cells in the luminal layers of the tubules. Most of the large dilated tubules and some of the small-to-moderate-sized tubules expressed immunophenotypes similar to those of the eccrine dermal duct. The other tubular structures, including the small tubules resembling those of syringoma, expressed immunophenotypes similar to those of the transitional portions between the dermal ducts and the secretory segments of eccrine glands. From the above comparative studies, papillary eccrine adenoma is considered to differentiate towards the dermal duct and the transitional portions between the dermal ducts and the secretory segments of eccrine glands.

[Transthoracic Doppler echocardiographic detection of intramyocardial coronary artery flow in humans using high frequency transducer]

The use of transthoracic color and pulsed Doppler echocardiography to detect intramyocardial coronary artery flow in humans was evaluated in 18 normal healthy subjects (mean age 54 years) and in 16 patients with hypertrophic cardiomyopathy (HCM; mean age 59 years) to measure the intramyocardial coronary artery flow velocity at the ventricular septum and the apex using a 10-5 or 7-4 MHz transducer. Linear inflow color Doppler signals which passed the interventricular septum were demonstrated in 15 of 18 normal subjects (83%) and 15 of 16 patients with HCM (94%). The phasic flow velocities measured by pulsed Doppler echocardiography consisted of two forward flow signals in mid-systole (S-wave) and holodiastole (D-wave), and were obtained in 11 of 18 in normal subjects (61%) and 14 of 16 patients with HCM (88%). The mean peak velocities of the S- and D-waves in patients with HCM (mean [+/-SD] 27 +/- 9 and 86 +/- 23 cm/sec, respectively) were significantly (p < 0.05) higher than those in normal subjects (18 +/- 4 and 54 +/- 11 cm/sec, respectively). At the apex, linear inflow color Doppler signals which passed the myocardium perpendicularly during the whole diastole were demonstrated in 14 of 18 normal subjects (78%) and all 16 patients with HCM (100%). The phasic flow velocities were measured by pulsed Doppler echocardiography in 10 of 18 normal subjects (56%) and 15 of 16 patients with HCM (94%). The mean peak velocities in patients with HCM (74 +/- 27 cm/sec) were significantly (p < 0.05) higher than those in normal subjects (33 +/- 13 cm/sec). Transthoracic color and pulsed Doppler echocardiography can detect intramyocardial coronary artery flow in humans at the interventricular septum and the apex noninvasively.

Thiocyanato and Iodo Complexation of Cadmium(II) Ions in Micellar Solutions of a Nonionic Surfactant Triton X-100

Complexation of the cadmium(II) ion with thiocyanate and iodide ions have been studied by precise titration calorimetry in micellar solutions of a nonionic surfactant Triton X-100 containing 0.4 mol dm-3 NaClO4 as a constant ionic medium at 298 K. With regard to the Cd(II)-SCN- system, the formation of [Cd(NCS)]+ and [Cd(NCS)(SCN)] in aqueous solution and [Cd(NCN)2(SCN)]- in micelles was established, though the complexation in micelles is not extensive. With the Cd(II)-I- system, the formation of [CdI]+, [CdI3]-, and [CdI4]2- was established in aqueous solution together with the formation of [CdI2], [CdI3]-, and [CdI4]2- in micelles. It is revealed that the complexation in micelles is accompanied by relatively large and negative enthalpies, which is ascribed to the enthalpies of transfer of [CdI3]- and [CdI4]2- from aqueous solution to micelles. This suggests that a hydrophobic complex with no capacity to form strong hydrogen bonds in water is favored in micelles.

[Quantitative evaluation of aqueous flare in psoriasis using a laser flare-cell meter]

We evaluated aqueous humor protein concentration in psoriasis using a laser flare-cell meter, which can quantify aqueous flare precisely and objectively. Psoriatic severity was evaluated on the basis of psoriasis area and severity index (PASI) score. Aqueous flare was measured in 40 eyes of 20 psoriasis patients (sixteen psoriasis vulgaris, three guttate psoriasis, and one psoriatic arthritis) and 28 eyes of 14 normal controls. Aqueous flare value was significantly higher in psoriatic patients than in normal controls (p < 0.01). There was no difference between psoriasis vulgaris and the other types of psoriasis. Aqueous flare value was higher in patients with psoriatic history longer than 10 years than in those with less than 10 years (p < 0.05), and also higher in patients with severe psoriasis (PASI score > 10) than in those with mild psoriasis (PASI score < 10) (p < 0.05). But no statistically significant differences in aqueous flare value were found among cyclosporin, etretinate, and psoralen ultra violet A therapies. These findings strongly suggest that patients suffering from psoriasis have slight damage of the blood-aqueous barrier even if they have no ocular symptoms, and that the degree of blood-aqueous barrier damage increases with time and severity of psoriasis.

DNA-ploidy abnormalities are a reflection of the metastatic potential of malignant melanoma. Microfluorometric DNA analysis

Using DAPI (4',6-diamidino-2-phenylindole)-DNA microfluorometry, we examined the nuclear DNA-ploidy abnormalities of 15 primary malignant melanomas and their 20 corresponding metastases. They all presented the aneuploid DNA histographic pattern. When the DNA index value was calculated as the reflection of DNA-ploidy abnormalities, it was found to be significantly higher in the metastases (2.07 +/- 0.50) than in the primary tumors (1.76 +/- 0.50) (p < 0.01). Sixteen (80%) of the metastatic tumors had a higher DNA index value than their primary tumors, whereas the remaining four (20%) had a lower value. The difference in the DNA index values between the primary and metastatic tumors did not correlate to any other conventional prognostic variables (e.g. histologic type, level, and thickness). When we added 15 non-metastatic melanomas to the above 15 primary melanomas and evaluated the predictors for metastasis using multivariate stepwise logistic regression analysis, the DNA index value of the primary melanomas was found to be the most reliable risk factor. These results suggest that primary melanoma cell populations, having high DNA index values, are usually responsible for subsequent metastasis, and that hence, DNA-ploidy abnormalities of primary melanomas are likely to provide useful information for patient potential with regard to metastasis.

In situ right internal thoracic artery graft via transverse sinus for revascularization of posterolateral wall: early results in 116 cases

The in situ right internal thoracic artery graft brought through the transverse sinus was used to revascularize the posterolateral wall in 116 patients. Its advantages were assessed retrospectively. The graft was anastomosed to the circumflex marginal branch in 70 patients (60%) or to the posterolateral branch in 41 patients (35%). One patient died (mortality rate 0.9%). Perioperative myocardial infarction occurred outside the territory of the right internal thoracic artery graft in 10 patients, four of whom required mechanical support for hemodynamic deterioration. Postoperative early angiography in 114 patients found the graft to be patent in 97.4%. The ratio of the diameter of the right internal thoracic artery to that of the recipient marginal branch was 0.94 +/- 0.18 (n = 69), and that to the posterolateral branch was 0.88 +/- 0.18 (n = 37) (not significantly different). Results of a postoperative stress test were abnormal in one patient (1/96 tested patients). This retrospective study suggests that the right internal thoracic artery brought through the transverse sinus to revascularize the posterolateral wall provided excellent early patency and good clinical results, even to the most distally located branches. This continues to be our procedure of choice for patients with multivessel coronary disease.

[Cerebral complication during open heart surgery in relation to cerebral arterial stenosis documented by angiography]

To determine the cause of a cerebral lesion after open heart surgery, a cranial 4-vessel-study was performed prior to an elective operation in 89 patients, who were over 70 years of age and/or had a previous history of cerebro-vascular diseases (CVD). Patients with arterial stenosis over 75% to complete obstruction were categorized as the significant stenosis group and the others as the normal findings group. Of the 89 cases, 19 (21.1%) showed significant stenosis, among which six patients were found to have complete occlusion of the internal carotid artery. Seven patients (7.9%) developed postoperative neurological complications, with four patients having single or plural significant stenosis. Angiograms of three of those four patients revealed complete obstruction of their internal carotid arteries. The stenotic group showed a tendency toward neurological complications in comparison with the non-stenotic group although the incidence was not significant (p = 0.054). However analysis of the group with complete occlusion of the internal carotid artery indicated significant increased risk for cerebral complication (p < 0.013). Besides the 89 patients studied, an additional 479 patients who had not undergone preoperative angiography were subjected to this study whether the patient's age, previous history of CVD and extracorporeal circulation (ECC) time or aortic cross-clamp time were of the risk factors for postoperative cerebral complications or not. There was significant correlation between age (p = 0.044) and/or the previous history of CVD (p < 0.001) and neurological complications. Although there was no correlation between either the duration of ECC or aortic cross-clamp time and neurological problems within the whole study population, when only the patients over 70 years old and/or having history of CVD were studied, an increased tendency towards neurological complications was seen when the ECC time was longer than 120 minutes (p = 0.045).

[Coronary artery bypass surgery in patients over 80 years]

Coronary artery bypass grafting (CABG) was being performed with increased frequency in elderly patients. However, the results of operations in patients over the age of 80 years have not been previously reported in Japan. Between May 1988 and September 1994, we have performed CABG in 28 patients over the 80 years of age (group A: mean 82.2). These patients were compared with 240 patients in 60s (group B: mean 65.0). Mean New York Association functional class (NYHA) was significantly higher in group A (p < 0.01). Left main trunk stenosis was more frequent in group A patients (p < 0.01), while the number of diseased vessels did not differ. Preoperative use of an intra-aortic balloon pump (29%) and emergency operation (54%) were more frequent in group A patients (p < 0.01). There was no significant difference in the number of grafts per patient between the groups (2.93 for group A versus 2.93 for group B), but the internal mammary artery was used more frequently in group B patients (99% versus 39%, p < 0.01). In group A, the major complicatines were stroke, cardiac tamponade, reoperatin for bleeding and respiratory failure in 1 patient each (3.6%). The hospital mortality did not differ between the groups (0% for group A and 2.9% for group B). In group A, at mean follow-up of 16.3 months, 25 patients (89%) are alive and no patient had recurrent angina. We conclude that CABG in patients over 80 years of age can be performed with low mortality and significant symptomatic benefit. Patients should not be denied CABG because of age alone.

[An evaluation of aortic root reconstruction using Carrel patch method with coronary anastomosis]

During the past 4 years, from January 1991 to December 1994, we experienced 12 cases of aortic root reconstruction utilizing Carrel patch method. The cases included annulo-aortic ectasia (AAE), root aneurysm with aortic regurgitation (AR), and aortic dissection with AR. The aortic valve and aortic root were resected, the coronary ostia were dissected free, mobilized, and then implanted to the composite graft. Coronary anastmosis was performed by mattress suture and reinforced by Tefron felt strips. It was necessary in one case to undergo coronary artery bypass grafting for myocardial ischemia due to coronary ostial stenosis. Operative procedure could be performed in 4 cases without blood transfusion. Post operative death was seen in only 1 case at 25 postoperative day, who underwent on emergency operation for cardiac tamponade due to aortic dissection. Pseudoaneurysm formations of coronary ostia or hospital death was not observed in any other cases during follow up period (average 25 months). Late tamponade was shown in one case as a complication, and the majority of cases had uneventful postoperative course. The operative procedure is considered feasible in any anatomic variation of the aortic root disease, even if dislocation of coronary ostia is minimal, and can be expect for prevention of pseudoaneurysm formation, and long term survival.

Hereditary multiple glomus tumors involving the glans penis. A case report and review of the literature

BACKGROUND

Multiple glomus tumors are extremely rare and seldom demonstrate malignant change.

OBJECTIVE

To describe an exceptionally rare case of familial multiple glomus tumors involving the glans penis.

METHODS

Multiple glomus tumors in a father and son were studied by light and electron microscopy.

RESULTS

The clinical presentation of the two patients was similar, and atypical glomus cells were identified in both son and father. The histology of the tumor cells suggested that they were malignant, yet the clinical course has been benign.

CONCLUSION

Despite their malignant histologic appearance, the behavior of familial glomus tumors is benign. A conservative approach to treatment appears warranted. The diagnosis and management of these lesions should be based on clinical behavior rather than histopathology.

Prognostic significance in malignant melanoma of nuclear DNA content measured by a microfluorimetric method

The nuclear DNA content of 47 primary malignant melanomas was measured by 4',6-diamidino-2-phenylindole-DNA (DAPI-DNA) microfluorimetry, and the DNA index, a quantitative measure of nuclear DNA content, was calculated. The DNA index and other clinical and pathological variables were examined and compared with patient survival using univariate and multivariate analyses. The Kaplan-Meier life table method revealed that the DNA index and metastases to regional lymph nodes significantly correlated with patient survival. A Cox proportional hazards multivariate analysis demonstrated that the DNA index, which was not significantly correlated with other variables, was the most reliable and independent factor for predicting patient survival.

Proton radiotherapy for malignant melanoma of the skin

BACKGROUND

Malignant melanoma, a tumor with reduced radiosensitivity, has been suggested to be overcome by a high-dose fractionation radiotherapy. The proton beam presents physical characteristics that enable such high-dose irradiation.

OBJECTIVE

Our aim is to answer whether or not the proton beam can provide useful treatment for cutaneous melanoma.

METHODS

Five primary melanomas (4 acral lentiginous and 1 superficial spreading type) and 3 metastatic lymph nodes of 3 different patients were irradiated using the proton beam with a total dose of around 100 Gy fractionated into single doses of approximately 10 Gy.

RESULTS

All the macular lesions and a tumor lesion of primary melanoma disappeared completely, and other tumor lesions regressed by 80-90%. The 3 metastatic lymph nodes also regressed by 50-90%. No severe radiation-related complication occurred.

CONCLUSION

Proton radiotherapy may prove to be a useful therapeutic modality for the management of cutaneous malignant melanoma.

[Multi-organ ischemia due to traumatic lesion of the descending thoracic aorta--a case-report]

This is a case of severe ischemic and reperfusion multi-organ failure due to descending thoracic aortic rupture. A 25 year-old man received a hard blow on his chest in a traffic accident. Chest X-ray, CT scans and aortogram elucidated descending thoracic aortic rupture. Emergency operation was performed 18 hours after the injury. The aortic rupture, 4/5 of the aortic circumference with intact adventitia was seen. The descending aorta 22 distal to the left subclavian artery was repaired under cardio-pulmonary bypass with selective cerebral perfusion. Ischemia due to aortic occlusion with thrombus and reperfusion injury after reconstruction of the aorta connected with rhabdmyolysis and severe multi-organ failure. Intestinal necrosis required laparotomy on the 9th and 15th post operative day. The patient died on 15th postoperative day of multi-organ failure.

Relationship between the degree of injury at operation and the change in antimyosin antibody titer in the postpericardiotomy syndrome

Successive measurements of cardiac myosin light chain I (MLC), creatine kinase isoenzyme MB (CKMB), and the titer of antimyosin antibody (AMA) were performed prospectively in 19 patients following open heart surgery. Seven of these patients showed the postpericardiotomy syndrome (PPS). No differences in serum concentrations of MLC or CKMB were observed between the patients with and without PPS, and all patients in both groups had abnormal MLC values after surgery. However, only patients with PPS had significantly elevated AMA titers. The maximum AMA titer was significantly correlated with the severity of the effusion. These data suggest that PPS is unrelated to the severity of myocardial injury during operation. Furthermore, the AMA titer may be useful as one of the indicators for determining the patient's clinical condition.

Proton radiotherapy of skin carcinomas

At the Proton Medical Research Center, University of Tsukuba, we performed a pilot study of proton-beam radiotherapy in 12 patients with the following types of carcinoma: Bowen's disease (4), oral verrucous carcinoma (5), and squamous cell carcinoma (3). They received total doses of 51-99.2 Gy in fractions of 2-12.5 Gy. All of the tumours responded well to the treatment. All four lesions of Bowen's disease, three of the five oral verrucous carcinomas, and the three squamous cell carcinomas completely regressed following irradiation. Two squamous cell carcinomas recurred during the follow-up period. One recurrent squamous cell carcinoma was successfully treated by a salvage surgical operation, and in the other case the patient refused further therapy. In two verrucous carcinomas there was 90% regression of tumour volume. No severe radiation-related complication occurred. As proton radiotherapy produces good local tumour control without significant morbidity to the surrounding normal tissues, it may prove to be a useful therapeutic modality for the treatment of skin carcinomas.

[Gastrointestinal complication after open cardiac operation]

Seven cases of abdominal complications necessitated laparotomies within 30 days after open heart surgery are presented. They consist of five cases of mesenteric infarction, one acalculous cholecystitis and one hemorrhagic ulcer of the rectum. The incidence is 0.9 percent at our institute. They also had a very complex course after their cardiac surgery such as cardiogenic shock, respiratory failure and renal failure prior to the development of their acute surgical abdomen. It is proposed that the cause of acute abdomen is attributed basically to the low cardiac output state. Surgery must be performed without delay because unnecessary passage of time is accompanied by unacceptable mortality rate.